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Emergency and Acute Medicine - Dialysis Complications
Basics
Description Dialysis complications may be vascular access related, nonvascular access related, or peritoneal. Vascular access complications include infection and bleeding. Nonvascular complications include hypotension and electrolyte disturbances such as hyperkalemia. Peritoneal complications most commonly involve abdominal pain and infection.
Etiology
Vascular access related complications include infections, which are a major cause of morbidity and mortality in dialysis patients and are most often caused by Staphylococcus aureus. These infections may present with localized signs, systemic sepsis, or minimal findings. Thrombosis or stenosis of access sites often presents with loss of bruit or thrill and requires urgent intervention to prevent access loss. Bleeding from access sites can be life-threatening and may be associated with aneurysm formation.
Nonvascular access related complications include hypotension, the most common complication of hemodialysis. This may occur during or after dialysis due to acute intravascular volume depletion, myocardial ischemia, sepsis, dysrhythmias, hypoxia, or cardiac tamponade unmasked by volume shifts. Hemorrhage may result from anticoagulation or platelet dysfunction related to renal failure. Shortness of breath may be caused by volume overload, tamponade, pericardial effusion, pulmonary embolism, air embolism, hemorrhage, or anaphylaxis. Chest pain may be ischemic due to high prevalence of atherosclerotic disease or pleuritic from pericarditis or pulmonary embolism. Neurologic dysfunction may occur due to disequilibrium syndrome caused by rapid decreases in serum osmolality during dialysis.
Peritoneal complications include peritonitis from contamination during exchanges, most commonly due to Staphylococcus aureus or Staphylococcus epidermidis. Perforated viscus presents with severe abdominal pain, fever, feculent effluent, or focal tenderness. Fibrinous catheter blockage may occur secondary to infection or inflammation.
Diagnosis
Signs and symptoms Vascular access complications present with bleeding from puncture sites, loss of bruit or thrill, local infection, fever, distal neurologic deficits, or enlarging masses near access sites. Nonvascular complications include hypotension, palpitations, syncope, chest pain, dyspnea, hemorrhage, and neurologic symptoms such as headache, malaise, seizures, or coma. Peritoneal complications present with abdominal pain, cloudy effluent, nausea, vomiting, or inflammation at the Tenckhoff catheter site.
Essential workup
A thorough physical examination is essential, including complete vital signs with auscultated blood pressure, pulse oximetry, and temperature. Evaluate for occult infection, volume overload, pulmonary findings, and cardiac abnormalities such as murmurs or pericardial rubs. Obtain ECG to assess for electrolyte disturbances or ischemia. Perform blood cultures, wound cultures, and peritoneal fluid analysis when infection is suspected. CBC and coagulation studies are required for bleeding. Chest radiograph, arterial blood gas, and cardiac enzymes are indicated for chest pain or dyspnea. Neurologic symptoms warrant brain imaging to exclude intracranial hemorrhage.
Diagnosis tests and interpretation
Lab studies include glucose, electrolytes, BUN, creatinine, and CBC. Imaging includes ECG for suspected hyperkalemia, pericarditis, effusion, or tamponade. Ultrasound of vascular access evaluates thrombosis or stenosis. Echocardiography assesses pericardial effusion or tamponade. CT angiography may be required for suspected pulmonary embolism, with careful coordination regarding contrast load and dialysis planning.
Differential diagnosis
Hypotension may be due to sepsis, cardiogenic shock, myocardial infarction, tamponade, dysrhythmias, electrolyte abnormalities, embolism, hypovolemia, or autonomic dysfunction. Neurologic symptoms may result from stroke, disequilibrium syndrome, metabolic derangements, hypoxemia, intracranial bleeding, infection, or uremia. Peritoneal symptoms require differentiation from hernia incarceration, perforated viscus, appendicitis, or cholecystitis.
Treatment
Pre hospital Avoid IV access and blood pressure measurement in limbs with functioning arteriovenous fistulas or grafts. Administer IV fluids cautiously and minimize volume. Use high-dose furosemide for pulmonary edema in anuric patients when appropriate.
Initial stabilization and therapy
Assess airway, breathing, and circulation. Control vascular access bleeding with firm pressure without fully occluding flow, document thrill afterward, and use hemostatic agents if needed. Treat hypotension by identifying the cause and administering fluids or vasopressors as indicated. Manage dyspnea with preload and afterload reduction and arrange urgent dialysis. Treat hyperkalemia with calcium, insulin with glucose, bicarbonate when appropriate, and cardiac monitoring, followed by dialysis. Address neurologic complications with glucose checks, naloxone, thiamine, and seizure control.
Emergency department treatment and procedures
Initiate empiric antistaphylococcal antibiotics for suspected access infections. Consult vascular surgery urgently for clotted access. Control hemorrhage and correct coagulopathies with fluids and blood products. Manage electrolyte disturbances and volume overload with medications and dialysis. Perform emergent pericardiocentesis for tamponade in unstable patients. Treat acute myocardial infarction according to standard protocols when appropriate. Manage peritonitis with IV or intraperitoneal antibiotics and obtain surgical consultation for suspected perforation.
Medication
Commonly used medications include calcium gluconate for cardioprotection in hyperkalemia, insulin with dextrose, sodium bicarbonate, loop diuretics, nitrates, ACE inhibitors, vasopressors, antistaphylococcal antibiotics, and intraperitoneal antibiotics for peritonitis.
Follow-up disposition
Admission criteria ICU admission is required for severe hyperkalemia, pulmonary edema, persistent hypotension, uncontrolled seizures, acute myocardial infarction, stroke, tamponade, sepsis, or severe peritonitis. General admission is indicated for fever, vomiting, nonsevere peritonitis, or inability to self-manage peritoneal dialysis.
Discharge criteria Patients with mild access-site infections, successful hemostasis, or select same-day thrombectomy procedures may be discharged with close follow-up.
Follow-up recommendations
Most dialysis patients require close follow-up with their nephrologist for ongoing management.
Pearls and pitfalls
Always consider hyperkalemia in dialysis patients. Cardiac tamponade may present atypically. Infections often have subtle presentations yet carry high mortality. Early vascular surgery consultation is critical for clotted or ruptured access sites.
Basics
Description Dialysis complications may be vascular access related, nonvascular access related, or peritoneal. Vascular access complications include infection and bleeding. Nonvascular complications include hypotension and electrolyte disturbances such as hyperkalemia. Peritoneal complications most commonly involve abdominal pain and infection.
Etiology
Vascular access related complications include infections, which are a major cause of morbidity and mortality in dialysis patients and are most often caused by Staphylococcus aureus. These infections may present with localized signs, systemic sepsis, or minimal findings. Thrombosis or stenosis of access sites often presents with loss of bruit or thrill and requires urgent intervention to prevent access loss. Bleeding from access sites can be life-threatening and may be associated with aneurysm formation.
Nonvascular access related complications include hypotension, the most common complication of hemodialysis. This may occur during or after dialysis due to acute intravascular volume depletion, myocardial ischemia, sepsis, dysrhythmias, hypoxia, or cardiac tamponade unmasked by volume shifts. Hemorrhage may result from anticoagulation or platelet dysfunction related to renal failure. Shortness of breath may be caused by volume overload, tamponade, pericardial effusion, pulmonary embolism, air embolism, hemorrhage, or anaphylaxis. Chest pain may be ischemic due to high prevalence of atherosclerotic disease or pleuritic from pericarditis or pulmonary embolism. Neurologic dysfunction may occur due to disequilibrium syndrome caused by rapid decreases in serum osmolality during dialysis.
Peritoneal complications include peritonitis from contamination during exchanges, most commonly due to Staphylococcus aureus or Staphylococcus epidermidis. Perforated viscus presents with severe abdominal pain, fever, feculent effluent, or focal tenderness. Fibrinous catheter blockage may occur secondary to infection or inflammation.
Diagnosis
Signs and symptoms Vascular access complications present with bleeding from puncture sites, loss of bruit or thrill, local infection, fever, distal neurologic deficits, or enlarging masses near access sites. Nonvascular complications include hypotension, palpitations, syncope, chest pain, dyspnea, hemorrhage, and neurologic symptoms such as headache, malaise, seizures, or coma. Peritoneal complications present with abdominal pain, cloudy effluent, nausea, vomiting, or inflammation at the Tenckhoff catheter site.
Essential workup
A thorough physical examination is essential, including complete vital signs with auscultated blood pressure, pulse oximetry, and temperature. Evaluate for occult infection, volume overload, pulmonary findings, and cardiac abnormalities such as murmurs or pericardial rubs. Obtain ECG to assess for electrolyte disturbances or ischemia. Perform blood cultures, wound cultures, and peritoneal fluid analysis when infection is suspected. CBC and coagulation studies are required for bleeding. Chest radiograph, arterial blood gas, and cardiac enzymes are indicated for chest pain or dyspnea. Neurologic symptoms warrant brain imaging to exclude intracranial hemorrhage.
Diagnosis tests and interpretation
Lab studies include glucose, electrolytes, BUN, creatinine, and CBC. Imaging includes ECG for suspected hyperkalemia, pericarditis, effusion, or tamponade. Ultrasound of vascular access evaluates thrombosis or stenosis. Echocardiography assesses pericardial effusion or tamponade. CT angiography may be required for suspected pulmonary embolism, with careful coordination regarding contrast load and dialysis planning.
Differential diagnosis
Hypotension may be due to sepsis, cardiogenic shock, myocardial infarction, tamponade, dysrhythmias, electrolyte abnormalities, embolism, hypovolemia, or autonomic dysfunction. Neurologic symptoms may result from stroke, disequilibrium syndrome, metabolic derangements, hypoxemia, intracranial bleeding, infection, or uremia. Peritoneal symptoms require differentiation from hernia incarceration, perforated viscus, appendicitis, or cholecystitis.
Treatment
Pre hospital Avoid IV access and blood pressure measurement in limbs with functioning arteriovenous fistulas or grafts. Administer IV fluids cautiously and minimize volume. Use high-dose furosemide for pulmonary edema in anuric patients when appropriate.
Initial stabilization and therapy
Assess airway, breathing, and circulation. Control vascular access bleeding with firm pressure without fully occluding flow, document thrill afterward, and use hemostatic agents if needed. Treat hypotension by identifying the cause and administering fluids or vasopressors as indicated. Manage dyspnea with preload and afterload reduction and arrange urgent dialysis. Treat hyperkalemia with calcium, insulin with glucose, bicarbonate when appropriate, and cardiac monitoring, followed by dialysis. Address neurologic complications with glucose checks, naloxone, thiamine, and seizure control.
Emergency department treatment and procedures
Initiate empiric antistaphylococcal antibiotics for suspected access infections. Consult vascular surgery urgently for clotted access. Control hemorrhage and correct coagulopathies with fluids and blood products. Manage electrolyte disturbances and volume overload with medications and dialysis. Perform emergent pericardiocentesis for tamponade in unstable patients. Treat acute myocardial infarction according to standard protocols when appropriate. Manage peritonitis with IV or intraperitoneal antibiotics and obtain surgical consultation for suspected perforation.
Medication
Commonly used medications include calcium gluconate for cardioprotection in hyperkalemia, insulin with dextrose, sodium bicarbonate, loop diuretics, nitrates, ACE inhibitors, vasopressors, antistaphylococcal antibiotics, and intraperitoneal antibiotics for peritonitis.
Follow-up disposition
Admission criteria ICU admission is required for severe hyperkalemia, pulmonary edema, persistent hypotension, uncontrolled seizures, acute myocardial infarction, stroke, tamponade, sepsis, or severe peritonitis. General admission is indicated for fever, vomiting, nonsevere peritonitis, or inability to self-manage peritoneal dialysis.
Discharge criteria Patients with mild access-site infections, successful hemostasis, or select same-day thrombectomy procedures may be discharged with close follow-up.
Follow-up recommendations
Most dialysis patients require close follow-up with their nephrologist for ongoing management.
Pearls and pitfalls
Always consider hyperkalemia in dialysis patients. Cardiac tamponade may present atypically. Infections often have subtle presentations yet carry high mortality. Early vascular surgery consultation is critical for clotted or ruptured access sites.
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